Appendix A

The Commonwealth of Massachusetts
Executive Office of Health and Human Services
Department of Public Health
250 Washington Street, Boston, MA 02108-4619
Suicide Prevention Resource Questionnaire

Help us identify resources for this Suicide Prevention Resource Guide
Please complete this survey only if you or your agency provide any type of suicide prevention services.
Fax completed surveys to Alan Holmlund at (617) 624-5075.

Your Name:_________________________ Agency Name:____________________________ Title:______________________________ Address:_________________________________
Phone: (_____)______________________ ________________________________________
E-mail:____________________________ Fax: ____________________________________

For the following questions, please circle all that apply to you and/or your organization.

What are the main services that you or your agency provide?

1. Mental Health Services
2. School-Based Services
3. Substance Abuse Treatment and Prevention
4. Hotline/Crisis Center
5. Education/Training – Subject matter: __________________
6. Elder Services
7. Other____________________________

Which of the following suicide prevention services do you or your agency provide?

1. Phone Counseling/Hotline
2. Advocacy
3. Mental Health Screening
4. Treatment and Intervention
5. Support Groups
6. Education and Training
7. Crisis Response
8. Other_______________________________________

What is your target population for suicide prevention services?

1. Teens/young adults
2. Adults
3. Seniors
4. All ages
5. Gay Lesbian Bisexual Transgender Youth
6. Non-English speaking community

Which of the following regions are covered by your services:

1. Metro Boston
2. Northeastern Massachusetts
3. Southeastern Massachusetts
4. Cape Cod
5. Central Massachusetts
6. Western Massachusetts
7. Other____________________

In what languages do you provide suicide prevention/intervention services?

1. English
2. Spanish
3. Vietnamese
4. Russian
5. Chinese
6. Other_______________

Do you provide suicide prevention resource/materials in various languages?
Yes____ No____ If yes, please list languages: _________________________________

If you offer suicide prevention resources, what type of information do you provide?

1. Newsletter
2. Website/Listserve Web address:________________________________
3. Library/Resource Center
4. Brochures
5. Curriculum/Manuals
6. Other______________________

If you provide suicide prevention education and training, what is the focus of your training?

1. Professional training to service providers/professionals
2. Gatekeeper training
3. Promote mental health/resiliency
4. Anti-stigma campaigns
5. Other___________________________

What would be helpful to you in a suicide prevention resource guide?

1. Professional Training/Curriculum
2. Index of Materials
3. Contact names (for referral)
4. Other service providers in field (for networking)
5. Data
6. Other________________________________

Next Chapter